Elevating the Post-Acute and
Long Term Care Profession

May 4, 2021

Director's Orders Released. Yesterday, we reported Governor Mike DeWine's announcement that Ohio would adopt the portion of new Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) guidance exempting fully vaccinated facility staff from routine COVID-19 testing. At that time, the Department of Health (ODH) orders had not been changed. Today, ODH released new testing orders signed by Director Stephanie McCloud. Along with the residential care facility (RCF) and SNF orders, ODH circulated new versions of the reopening orders for senior adult day services and senior centers, both of which include references to testing. In all cases, the orders adopt the federal exemption for fully vaccinated individuals.

  • Both the RCF and the SNF orders call for twice-weekly testing of unvaccinated staff instead of basing testing frequency on county positivity or another metric. For SNFs, the CMS guidance uses positivity.
  • The SNF order adds, "[r]egardless of vaccination status, staff and residents with symptoms or signs of COVID-19 shall be tested. ... Regardless of vaccination status, all staff and residents shall be tested upon identification of a single new case of COVID-19 infection in any staff or resident, unless the exposure to COVID-19 was outside of the facility and they did not enter the facility while potentially infectious. Exposed residents and staff should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 for a period of 14 days."
  • The RCF order is different and does not have a specific reference to outbreak testing: "Regardless of vaccination status, strategic testing of all staff and residents shall continue. Strategic testing may include, but is not limited to, testing staff and residents with known or suspected COVID-19 exposure; testing symptomatic staff and residents; or testing staff and residents as determined clinically necessary."
As a reminder, the ODH survey branch maintains that they do not enforce Director's orders through the survey process. ODH's Rebecca Sandholdt again confirmed this principle today, for both SNFs and RCFs.

Also, just as the testing orders and guidelines apply to hospice staff and other contracted personnel providing services in facilities, so does the vaccination exemption. We recommend verifying and documenting vaccination status for these individuals the same as you do for their testing status.

Applying the New Federal Post-Vaccination Guidance. On today's SNF member call, members engaged in a vigorous discussion about the new CDC guidance that eliminates masking and distancing requirements for health care personnel (HCP) and facility residents under certain circumstances, but only if they are fully vaccinated. The circumstances at issue primarily are types of gatherings, although routine staff testing also is involved, as mentioned above. In the gathering scenarios, if unvaccinated individuals are present, even vaccinated residents or staff must use masks and maintain social distance. To effectuate CDC's recommended changes, it is necessary to identify who is fully vaccinated and to give them greater latitude than people who have not been vaccinated. This, in turn, leads to questions about individuals' rights to choose not to be vaccinated and to keep their vaccination status private.

CDC speaks to this issue rather clearly in the guidelines:

Determining the vaccination status of patients/residents/HCP at the time of the activity might be challenging and might be subject to local regulations. When determining vaccination status, the privacy of the patient/resident/HCP should be maintained (e.g., not asked in front of other patients/residents/HCP). For example, when planning for group activities or communal dining, facilities might consider having patients/residents sign up in advance so their vaccination status can be confirmed and seating assigned. 

In other words, one should be respectful when distinguishing between vaccinated and unvaccinated people, but the distinction still must be made. While individuals can choose not to be vaccinated, infection control considerations - which are enforced through survey - require consequences for that choice. CDC recognizes it is appropriate to recognize and confer privileges on those who choose to be vaccinated. The ultimate goal is to encourage more staff and residents to be vaccinated. We do not recommend either denying the benefits of the new, relaxed guidance to vaccinated individuals or allowing unvaccinated individuals to enjoy those benefits.

Eye Protection and County Positivity. After our article last night about the high proportion of green counties on the latest CMS positivity table for Ohio, we received questions about the impact of this development on the need for SNF staff to wear eye protection. Per the most recent CDC SNF guidance, in facilities located in areas of moderate to substantial community spread (interpreted as CMS yellow or red counties), "[e]ye protection should be worn during patient care encounters to ensure the eyes are also protected from exposure to respiratory secretions." In areas of minimal to no community spread (CMS green counties), use of eye protection is based on "anticipated exposures and suspected or confirmed diagnoses." That is, eye protection is necessary when full personal protective equipment is required:

  • When caring for someone with COVID-19.
  • When caring for someone who is in quarantine.
  • In the event of an outbreak.